Are you still pouring your Post-2015 water investments ...€¦ · Types of Costs Considered Health Care Total Productivit y Premature Mortality Handwashing Practices Without 21.42

Are you still pouring your Post-2015 water investments down the drain?

Stockholm World Water Week

September 2, 2014

Hanna Woodburn, Global Public-Private Partnership for Handwashing

Orlando Hernandez, USAID WASHplus Project

Jane Wilbur, WaterAid

Corrie Kramer, Plan USA #KeepTheHinWASH

WASH Pre- and Post-2015

Water & Sanitation in the Millennium Development Goals • Target: Halve, by 2015, the proportion of the population

without sustainable access to safe drinking water and basic sanitation

WASH Post-2015 (as of July 19) • Goal 6: Ensure availability and sustainable management of

water and sanitation for all

Joint Monitoring Programme’s Proposed Target By 2030: • to eliminate open defecation; • to achieve universal access to basic drinking water, sanitation

and hygiene for households, schools and health facilities; • to halve the proportion of the population without access at

home • to safely managed drinking water and sanitation services;

and to progressively eliminate inequalities in access.

How to get a full return on your WASH investment

• Not just a behavior • Not just an afterthought

• An essential

Hygiene = Handwashing with Soap Menstrual Hygiene Management

Agenda

The “H, N & 3E” approach to hygiene

Hygiene has positive impacts on: • Health & Nutrition

• Economic development

• Equity

• Educational achievement

Call to Action

Q&A

WASH Component Studies Reviewed

(random or quasi-random control trials)

Self-reported diarrheal

disease in different age

groups

Water quality improved (treatment at

source or at point of use) 38 studies

15-61% separate studies

17% pooled effect

Sanitation (any measure to hygienically

dispose of human feces)

8 studies

Bangladesh, China, Ivory Coast,

Kenya, Nigeria, USA


36% pooled effect

Handwashing with soap

17 studies

Australia, Burundi, China, Peru,

Malawi


43% pooled effect

.

Cairncross S., C. Hunt, S. Boisson, K. Boesten, V. Curtis, I. Fung y, and W. Schmidt. 2010. Water, sanitation and hygiene for diarrhea prevention. International Journal of Epidemiology, 39: i193-i205.

Role of WASH in Diarrheal Disease Prevention, A Known Meta-analysis

Hygiene = Good health & nutrition

Making an Economic Case for Investing in Handwashing with Soap

Orlando Hernandez, John Bratt and Mackenzie Green

Stockholm World Water Week

September 2014

Outline of Presentation

• Not washing hands ends

up being costly for

a country

• Methodology

• Findings for example

country: Kenya

• Conclusion

Introduction

• Make the case that poor handwashing practices can have

negative economic consequence for a country

• Adapt the Economics of Sanitation Initiative (ESI)

approach to do a cost/benefit analysis of handwashing

practices in countries

• Apply the ESI approach in two steps, first to determine

costs and second to establish cost/benefit

• Focus on countries where WASHplus has programs:

Bangladesh, Benin, Kenya, Mali and Zambia

Elements of Methodological

Model for Calculations

Types of Costs Considered

Health Care

Productivity

Premature Mortality

Diseases Averted

Diarrhea

Respiratory Tract Infections

Health Care Cost per Disease

Element of Algorithm Source Kenya

Diarrhea ARI

1. Population at risk, <5

World Bank 7,051,217 children

2. Incidence rate of disease per person/year

Latest DHS/MICS

3.45 1.32

3. # of annual cases in population at risk

#1 x #2 21,424,869 (88% of fecal-oral

route)

4,644,402 (50% to fecal oral-route)

4. Proportion may be seeking care at facility for disease of interest

Latest DHS/MICS

0.486 0.559

5. Number of visits per episode

Hutton, WASH 2012 1.2 1 (value

unknown)

6. Cost per visit

WHO-CHOICE (cost estimates) US$1.73 US$1.73

7. Proportion of episodes avoided by handwashing (low and high)

Schmidt 2014 citing: Curtis and Cairncross 2003; Clasen et al., 2007; Ejemot et al. 2008

Low 30% Intermediate 40%

High 50%

Low 10% Intermediate

20% High 30%

Total cost without handwashing = 1 x 2 x 4 x 5 x 6 = $ 26.1 m

Total cost with handwashing = previous value by 7 = $12.2 m

Productivity Costs per Disease

Element of algorithm Source

1. Population at risk, <5

World Bank

2. Incidence rate of disease per person/year

Latest DHS/MICS

3. # of annual cases in population

#1 x #2

4. Number of productivity days lost per episode of disease

WSP, Hutton WASH 2012



Total cost without handwashing = 3 x 4

Total cost with handwashing = previous value by 5

Premature Mortality Cost

Element of algorithm Source

1. Estimated annual number of premature deaths associated with disease in vulnerable population segment

WHO World Statistics, WSP in country

2. Value imputed to premature death

World Bank World Databank; Hutton WASH 2012



Total cost without handwashing = 1 x 2

Total cost with handwashing = previous value by 3


Total Health Care

Productivity

Premature Mortality

Handwashing Practices

Without

21.42 11.09 173.96 206.47

With

10.81 5.54

86.98 103.32

Cost savings 10.62 5.55 86.98 103.15

Preliminary Calculations for Kenya:

Total Costs of Diarrhea Incidence without and with

Handwashing (High Impact) in US$ millions


Total

Health Care

Productivity

Premature Mortality

Handwashing Practices

Without

4.49 6.01 156.57 167.07

With

3.14 4.21 109.59 116.94

Cost savings 1.35 1.8 46.98 50.13

Preliminary Calculations for Kenya:

Total Costs of ARI Incidence without and with

Handwashing (High Impact) in US$ Million

Total Savings

Kenya Preliminary Estimates

• Premature mortality is driving the costs (similarly to finding of ESI)

• US$103.15 m from diarrhea + US$50.13 m from ARI = US$153.28

m

• USAID’s development assistance to Kenya was US$261 m in FY

2013, 58% of the hw savings

• 2013-14 estimated public sector expenditures in the health sector

was US$404 m, savings generated by hw represents 37% of that

budget

• Cost/benefit analysis is next, if we find funding

Breaking the silence

Menstrual

Hygiene

Management &

WASH

Jane Wilbur

Equity and Inclusion Advisor

WaterAid

Photo: Tridhara Photography/Anisur Rahman

• Females menstruate for approximately

3000 days (>8 years) during their life.

• They need:

• Water to wash their body and

materials used.

• Proper disposal of used materials

in a safe and dignified way.

• Yet, there is no mechanism for the

international community to track this

issue.

• And menstruation is surrounded by

stigma, silence and taboo.

Photo: WaterAid / Caroline Irby

The importance of MHM

Bangladesh: women must bury

menstrual cloths to banish evil

spirits.

Zambia, Nigeria, Tanzania: a

woman will be cursed if anyone

sees the menstrual cloth.

UK: if you use a tampon, you will

lose your virginity

Menstruating females may not be

allowed to touch water points, or

household sanitation facilities.

Myths

Photo: WaterAid/Behallu Shiferaw

• “When people come and see us at the Chhaupadi, I feel ashamed. I feel so

ashamed”. Thyra Khuri Bishwa Karma, 16. (Narsi village, Nepal).

Social exclusion

Photos: WaterAid/Paulomi Basu

• Ethiopia: 50% of girls in one school missed between 1-4 days of school per

month due to menstruation

Impacts on education

Photo: WaterAid/Behallu Shiferaw

• Bangladesh: 60% of female

factory workers used rags

from the factory floor as

menstrual cloths.

• Subsequent infections led

73% of these women to miss

c. 6 days a month of work.

• With MHM, this dropped to

3%.

• Result: economic gains for

workers and the factory

owner.

Economic impacts

Photo: WaterAid/Abir Abdullah

WASH programmes

• WASH projects focus on

women as managers who

ensure proper use and

maintenance.

• Sanitation and hygiene

facilities ignore the need for

menstruation hygiene

management.

• This reinforces the stigma and

shame surrounding

menstruation.

Photo: WaterAid/Brent Stirton

Menstrual Hygiene requires: 1) access to accurate and

pragmatic information

Photo: WaterAid/ James Kiyimba

• Girls’ books in different countries, local languages, culture and stories

• IEC materials – pictures for those who cannot read – depicting local

context

Work with both genders

When my first daughter experience[d] her

menstruation I was very mad and punished

her hard because I thought she was raped or

got into some kind of sexual intercourse with

boys. As a father I had very limited knowledge

about it. Now I truly regret it after getting this

knowledge about the subject.

Father in Ethiopia, 2014

2) Access to menstrual hygiene materials

A community worker holds a packet of sanitary towels in India.

Photo: WaterAid/ Poulomi Basu

3) Access to water and soap within a place that provides

an adequate level of privacy for washing body, cloths

and clothes

School girls bathrooms have water containers and buckets to wash

their bodies, clothes and menstrual hygiene materials

(Uganda).


4) Access to facilities that provide privacy for changing

materials and washing and drying menstrual cloths


School bathroom have places to dry pants and

menstrual hygiene materials after washing (Uganda).

5) Access to disposal facilities for used

menstrual materials

Integral incinerator

with girl-friendly

toilet

block, Afghanistan

(UNICEF)

Latrine block with

incinerator, changing

room with mirror so

women can check

their dress for stains.

Photos - right: Unicef; left: Menstrual hygiene matters, toolkit 3

Progressively reducing inequalities

Vision: by 2030 basic drinking water, adequate

sanitation, handwashing and menstrual hygiene

management in schools and health centres; basic water

at home; handwashing at home

Indicators: Percentage of primary and secondary

schools, hospitals, health centres and clinics with a

private place for washing hands, private parts and

clothes; drying re-usable materials; and safe disposal of

used menstrual materials.

This indicator should be included under the sexual and

reproductive health and reproductive rights goal.

Menstrual education and hygiene for all

There can be

no excuses.

Leave no-one

behind!

Photo: WaterAid / ASM Shafiqur Rahman

Are you still pouring your post-2015

water investments down the drain?

Hygiene and education

Corrie Kramer

Plan International USA

Burden of Disease | 02 September 2014 33 |

The good news

11

6.5

2.5

1.5 1.7

0.622 0

2

4

6

8

10

12

1990 2012

Mil

lio

ns

U5 deaths

Diarrhoeal deaths (Total)

Diarrhoeal deaths (U5)


Diarroeal Deaths and WASH

2.5

1.5

1.7

0.62

1.26

0.75

1.28

1.01

0.0

0.5

1.0

1.5

2.0

2.5

3.0

1990 2012

Mil

lio

ns

Diarrhoeal deaths (Total)

Diarrhoeal deaths (U5)

Unimproved water

Open defecation


Impacts of handwashing

Impact: reduction of diarrhoea by 23%

Freeman et al. 2014

14% 16%

14% 15% 17%

13%

49%

44% 44% 43%

19%

0%

10%

20%

30%

40%

50%

60%

Afr AmrLMI

EmrLMI

EurLMI

Sear WprLMI

AmrHI

EmrHI

Eur HI WprHI

World

Han

dw

ash

ing

pre

vale

nce

Promising Futures,

Community by Community

23% of poor, rural girls in sub-Saharan Africa complete primary school

Gender disparities more prevalent at higher levels of education

Girls in school

9/2/2014 36

Promising Futures,


4.1: free, equitable and quality primary and secondary education

4.5: eliminate gender disparities in education

4.a: education facilities that are child, disability and gender sensitive and provide safe, non-violent, inclusive and effective learning environments for all

6.2: access to adequate and equitable sanitation and hygiene for all

OWG proposed goals

9/2/2014 37

Promising Futures,


Education and behavior change

Education, health and hygiene are closely interlinked: good health and proper hygiene keep children in school and improve performance and learning.

On its part, the school is a strategic venue for instilling life-long health and hygiene behaviour among schoolchildren, who, themselves, become agents of behaviour change in their households and communities.

Promising Futures,


WASH in schools

In a cluster randomized trial, Freeman and

colleagues found children from 20 Kenyan government primary schools who received a school-based water treatment, hygiene and sanitation program had 44% lower odds of reinfection of Ascaris Lubricoides compared to children from 20 control schools.

Girls from intervention schools had lower odds of reinfection and lower egg count compared to girls from control schools. There was no difference between boys. There was no significant effect of the intervention on the reinfection of 3 other soil-transmitted helminths. (Freeman et al. 2013)

Promising Futures,


WASH and absenteeism

Joshi and colleagues reviewed recent evidence of the impact of

access to safe water, handwashing facilities and hygiene education on absenteeism and health outcomes among school-aged children.

Of the 5 studies that assessed WASH and absenteeism, the

authors found that incorporating an educational component in interventions was very effective in reducing absenteeism. Access to handwashing instructions and facilities improved primary school attendance during flu season.

The benefits of handwashing appeared greater in female students who had the highest absence rates. These studies relied on self-report for compliance and illness. Those with a lower socioeconomic index had worse access to safe water and improved sanitation and hygiene infrastructure compared to higher indices. (Joshi and Amadi 2013)

Promising Futures,


Fewer absences

In a randomized controlled trial among urban

Indian households, authors found that children from intervention households had 25% fewer diarrheal episodes, 15% fewer ARI episodes and 27% fewer school absences due to illness, and 46% fewer eye infections compared to controls. Families of intervention children also had fewer episodes of illness compared to families of control children. (Nicholson et al. 2014)

Promising Futures,


Hygiene is the missing link in achieving the full benefits of your WASH investments

Governments

• Measure access

• Create hygiene-friendly policies

• Support hygiene in the Post-2015 agenda

NGOs

• Integrate hygiene into correlated projects

• Advocate for better hygiene policies at the country level

Donors

• Fund comprehensive WASH projects

• Promote hygiene integration

Questions & Answers

Thank you!

Hanna Woodburn PPPHW [email protected]

Orlando Hernandez USAID WASHplus/FHI 360 [email protected]

Jane Wilbur WaterAid [email protected]

Corrie Kramer Plan USA [email protected]

mailto:[email protected]
















Documents

Are you still pouring your Post-2015 water investments ...€¦ · Types of Costs Considered Health Care Total Productivit y Premature Mortality Handwashing Practices Without 21.42